MEDICARE: FORT WELLNESS, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	13854416	OTHER	TX	CAQH

General Provider Information

NPI Number	:	1285181727
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT WELLNESS, PLLC

Provider Business Mailing Address
First Line	:	1809 RIDGMAR BLVD.
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-2018
Country	:	US
Telephone Number	:	682-232-4003
Fax Number	:

Provider Business Practice Location Address
First Line	:	1809 RIDGMAR BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-2018
Country	:	US
Telephone Number	:	682-232-4003
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. RANE PERRY WALLACE
Credential	:	MS, LPC-INTERN, LCDC
Telephone Number	:	682-232-4003

Provider Enumeration Date	:	09/01/2016
Last Update Date	:	09/01/2016

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